Approval Specialist

Role Overview

The Approval Specialist will be responsible for managing medical preauthorization activities, ensuring that requests comply with Council of Health Insurance (CHI) preauthorization requirements, NPHIES standards, and each payer’s coverage rules. The role focuses on preventing non-covered or non-contracted services from being initiated, supporting downtime contingency processes, and maintaining timely, accurate approval handling across the patient journey.

Core Responsibilities

• Follow CHI preauthorization policy, NPHIES requirements, and individual payer protocols without exception.
• Stop unauthorized, uncovered, or non-contracted services from being started.
• Support and apply NPHIES downtime contingency procedures when needed.
• Check that clinical documents are complete and that the Minimum Data Set (MDS) is used for every request.
• Review treating physicians’ progress notes, diagnostic results, prescriptions, and clinical rationale to confirm they are sufficient and accurate.
• Assess medical necessity against evidence-based guidelines, CHI rules, and payer criteria.
• Ensure coding and scheme mapping are accurate to reduce claim rejections.
• Send back incomplete or incorrect documentation for correction before submission.
• Work with physicians, nurses, and roving doctors to obtain approvals and clarify case details.
• Issue approvals, denials, and payer responses within CHI-required timelines.
• Respond to payer or insurer questions within 30 minutes of receiving them.
• Immediately escalate urgent or high-priority cases such as ER, ICU, Oncology, or costly procedures to the Preauthorization Manager.
• Track HIS and NPHIES queues in real time and follow up on pending or queried cases.
• Keep approval status updated in both the HIS and the patient record.
• Ensure all discharge approvals are completed the same day, with 100% completion target.
• Confirm same-day discharge cases and high-cost cases are approved before billing begins.
• Record every approval, denial, and payer interaction in the medical record.
• Take part in daily discharge reconciliation and report pending approvals to the Preauthorization Manager.
• Review preauthorization rejections from NPHIES, payer portals, or HIS at least twice per shift.
• Classify each rejection by cause, such as missing justification, duplication, non-covered service, exceeded limits, coding mistakes, or late submission.
• Log all rejections in the Rejection Tracker with MRN, preauthorization number, payer name, rejection reason, and physician name.
• Work with the Preauthorization Supervisor to ensure each rejection is reviewed and analyzed within the assigned turnaround time.
• Contact the treating physician directly for clarifications or missing supporting documents related to rejected cases.
• Provide practical guidance to physicians to reduce repeat rejections using insurer rules, CHI guidance, and NPHIES dataset requirements.
• Hold same-day briefings for rejections involving expensive services.
• Resubmit corrected documentation within the payer’s appeal window according to the applicable regulations.
• Coordinate urgent or high-priority resubmissions with the insurance representative or roving doctor.
• Verify that resubmitted cases are acknowledged in both HIS and payer systems.
• Identify the root cause of each rejection and document recommended corrective actions.
• Separate avoidable and non-avoidable rejections during end-of-day review.
• Prepare and submit a daily rejection summary to the Preauthorization Manager covering total rejections, avoidable vs. non-avoidable ratio, recurring or high-value patterns, and breakdowns by payer, physician, and service category.
• Recommend fixes such as MDS checklist updates, justification templates, or targeted physician education sessions.
• Work with Fakeeh Tech to improve HIS alerts, including automatic flags for incomplete documentation or incorrect scheme linkage.
• Join weekly Preauthorization Group performance meetings to present rejection trends and lessons learned.
• Maintain full transparency of rejection cases with the Preauthorization Manager and Group Preauthorization leadership.
• Support the Weekly Rejection Dashboard with total rejection count, avoidable vs. non-avoidable percentage, average approval turnaround time, top contributing services/physicians/payers, and immediate corrective actions with follow-up plans.
• Keep communication professional and ensure all internal and external correspondence is formally documented.
• Maintain ongoing compliance with CHI, NPHIES, and contractual payer requirements throughout preauthorization and rejection handling.
• Report process deviations or non-compliance to the Preauthorization Manager immediately for correction and group review inclusion.
• Perform any other duties that fall within the role’s scope and responsibilities.

Requirements

• 3 to 5 years of clinical practice experience, including at least 2 years in preauthorization, insurance, or utilization management.
• Bachelor’s degree in Medicine and Surgery, Pharmacy, Dental, or a closely related field.
• Strong spoken and written communication skills in both English and Arabic.
• Preferred professional license to practice under the relevant regional health authority, such as SCFHS or DHA.

Additional Information

This is a full-time onsite role based in Riyadh, Riyadh, Saudi Arabia. The position requires close coordination with clinicians, insurance stakeholders, and internal preauthorization leadership to ensure timely approvals, accurate rejection handling, and strict adherence to payer and regulatory standards.

Note: No salary, benefits, number of vacancies, or start date were provided in the source content.